The Relational Mind in Couple Therapy: A Bateson-Inspired View of Human Life as an Embodied Stream.

Research on human intersubjectivity has found that humans participate in a dialogue throughout their life, and that this is manifested not only via language, but also nonverbally, with the entire body. Such an understanding of human life has brought into focus some basic systemic ideas concerning the human relational mind. For Gregory Bateson, the mind works as a system, formed from components that are in continuous interaction with each other. In our Relational Mind research project, we followed twelve couple therapy processes involving two therapists per session, looking at the ways in which the four participants attuned to each other with their bodies, including their autonomic nervous system activity. Using observations from the project, we here describe the ways through which the relational and embodied mind can be realized in a couple therapy setting.

Attachment Versus Differentiation: The Contemporary Couple Therapy Debate.

This paper reviews the current debate between differentiation and attachment in treating couples through exploring the tenets of crucible therapy (Schnarch, 1991) and emotionally focused couple therapy (Johnson, 2004). We provide a review of the two theories-as well as the two "pure form" example models-and explore the debate in light of the integrative movement in couple and family therapy (Lebow, 2014). We also examine points of convergence of the two theories and models, and provide clinicians and researchers with an enhanced understanding of their divergent positions. Both differentiation and attachment are developmental theories that highlight the human experience of balancing individuality and connection in adulthood. The two models converge in terms of metaconcepts that pervade their respective theories and approach. Both models capitalize on the depth and importance of the therapeutic relationship, and provide rich case conceptualization and processes of therapy. However, they substantially differ in terms of how they view the fundamental aspects of adult development, have vastly divergent approaches to how a therapist intervenes in the room, and different ideas of how a healthy couple should function. In light of the deep polarization of the two models, points of integration-particularly between the broader theories of attachment and differentiation-are offered for therapists to consider.

Dyadic Coping in Couple Therapy Process: An Exploratory Study.

This study aimed at moving beyond previous research on couple therapy efficacy by examining moment-by-moment proximal couple and therapist interactions as well as final treatment outcomes and their reciprocal association. Seven hundred four episodes of dyadic coping within 56 early therapy sessions, taken from 28 married couples in treatment, were intensively analyzed and processed using a mixed-methods software (T-LAB). Results showed that negative dyadic coping was self-perpetuating, and therapists tended to passively observe the negative couple interaction; on the contrary, positive dyadic coping appeared to require a therapist's intervention to be maintained, and successful interventions mainly included information gathering as well as interpreting. Couples who dropped out of treatment were not actively engaged from the outset of therapy, and they used more negative dyadic coping, whereas couples who successfully completed treatment showed more positive dyadic coping very early in therapy. Results highlight the role of therapist action and control as critical to establishing rapport and credibility in couple therapy and suggest that dyadic coping patterns early in therapy may contribute to variable treatment response.

Couple Therapy with Veterans: Early Improvements and Predictors of Early Dropout.

Family services within Veterans Affairs Medical Centers fulfill an important role in addressing relationship distress among Veterans, which is highly prevalent and comorbid with psychopathology. However, even for evidence-based couple therapies, effectiveness is weaker compared to controlled studies, maybe because many Veteran couples drop out early and do not reach the "active" treatment stage after the 3-4 session assessment. In order to improve outcomes, it is critical to identify couples at high risk for early dropout, and understand whether couples may benefit from the assessment as an intervention. The current study examined (a) demographics, treatment delivery mode, relationship satisfaction, and psychological symptoms as predictors of dropout during and immediately following the assessment phase, and (b) changes in relationship satisfaction during assessment. 174 couples completed questionnaires during routine intake procedures. The main analyses focused on 140 male Veterans and their female civilian partners; 36.43% dropped out during the assessment phase and 24.74% of the remaining couples immediately following the first treatment session. More severe depressive symptoms in non-Veteran partners were associated with dropout during assessment. Relationship satisfaction improved significantly during the assessment phase for couples who did not drop out, with larger gains for non-Veteran partners. No demographics or treatment delivery mode were associated with dropout. Although more research is needed on engaging couples at risk for early dropout and maximizing early benefits, the findings suggest that clinicians should attend to the civilian partner's and Veteran's depressive symptoms at intake and consider the assessment part of active treatment.

Anger Can Help: A Transactional Model and Three Pathways of the Experience and Expression of Anger.

Anger is a significant human emotion with far-reaching implications for individuals and relationships. We propose a transactional model of anger that highlights its relational relevance and potentially positive function, in addition to problematic malformations. By evolutionary design, physical, self-concept, or attachment threats all similarly trigger diffuse physiological arousal, psychologically experienced as anger-emotion. Anger is first a signaling and motivational system. Anger is then formed to affirming, productive use or malformed to destructive ends. A functional, prosocial approach to anger organizes it for protective and corrective personal and relational adaptation. In our model, threat perception interacts with a person's view of self in relation to other to produce helpful or harmful anger. Inflated or collapsed views of self in relation to other produce distinct manifestations of destructive anger that are harmful to self, other, and relationship. Conversely, a balanced view of self in relation to other promotes constructive anger and catalyzes self, other, and relationship healing. Clinical use of the model to shape healing personal and relational contact with anger is explored.

Daily Events for Clinical Couples: Examining Therapy Interventions, Positive Events, Arguments, and Exercise in the Beginning Stage of Therapy.

This study examined the daily association of several events within the beginning phase of couple therapy. Events examined were as follows: trying something from therapy, an argument, a positive event, and physical exercise. Participants were 33 couples in a treatment-as-usual setting who completed the Daily Diary of Events in Couple Therapy (DDECT). A dyadic multilevel model was used to explore the daily associations between predictor and outcome variables. Results showed when male partners tried something from therapy at rates greater than the average their female partners reported a more positive relationship while when female partners tried something from therapy at rates greater than the average it contributed to a more negative relationship. In addition, results showed that clients in couple therapy rarely try things from therapy on a daily basis. Finally, relative to other predictors trying something from therapy had a smaller, but significant relationship with outcomes.

New Sexism in Couple Therapy: A Discursive Analysis.

The persistence of gender inequality in postindustrial societies is puzzling in light of a plethora of changes that destabilize it, including shifts in economy, legislation, and the proliferation of feminist politics. In family relations, such persistence manifests as a disconnect between couples aspiring to be more egalitarian yet continuing to enact traditional gender roles and hierarchies. There is an emerging consensus that gender inequality persists because of people's continued reliance on sexist ideology or gendered assumptions that constitute women as innately distinct from and inferior to men. Sexist ideology changes its form to accommodate to changing socio-economic conditions. Contemporary forms of sexism are old ways of legitimizing male power articulated in new and creative ways, often by incorporating feminist arguments. To effectively recognize and address "new sexism," scholars and practitioners require new, innovative research frameworks. Our objective in writing this article is two-fold. First, we seek to advance discursive (i.e., focused on language in use) approaches to the study of sexism. Second, we present the results of a discursive analysis of "new" sexist discourse in the context of couple therapy. The study provides preliminary evidence that, despite endorsing egalitarian norms, couples studied continue to rely on gender binaries and remain entrenched in old-fashioned patterns of gender inequality. Implications of these results for the practice of couple therapy and for future research are discussed.

Partner Pronoun Use, Communal Coping, and Abstinence during Couple-Focused Intervention for Problematic Alcohol Use.

Communal coping-a process in which romantic partners view a problem as ours rather than yours or mine, and take collaborative action to address it -has emerged as an important predictor of health and treatment outcomes. In a study of partners' pronoun use prior to and during couple-focused alcohol interventions, we examined first-person plural (we-talk) and singular (I-talk) pronouns as linguistic markers of communal coping and behavioral predictors of treatment outcome. Thirty-three couples in which one partner abused alcohol were selected from a randomized control trial (N = 63) of couple-focused Cognitive-Behavioral or Family Systems Therapy if they had unambiguously successful or unsuccessful treatment outcomes (i.e., patient maintained abstinence for 30 days prior to treatment termination or had more than one heavy drinking day in the same period). Pronoun measures for each partner were obtained via computerized text analysis from transcripts of partners' speech, derived from a videotaped pretreatment interaction task and three subsequent therapy sessions. Spouse we-talk during the intervention (accounting for pretreatment we-talk), as an index of communal orientation, uniquely predicted successful treatment outcomes. In contrast, both patient and spouse I-talk during the intervention (accounting for pretreatment I-talk), as a marker of individualistic orientation, uniquely predicted unsuccessful outcomes, especially when distinguishing active and passive (I vs. me/my) pronoun forms. Results strengthen evidence for the prognostic significance of spouse behavior for patient health outcomes and for communal coping (indexed via pronoun use) as a potential mechanism of change in couple-focused interventions for health problems.

Addressing Culture, Gender, and Power with Asian American Couples: Application of Socio-Emotional Relationship Therapy.

Asian Americans juggle the intersections of multiple social identities and societal discourses as they respond to experiences of immigration, marginalization, and patriarchy, integrate collectivist and individualistic family values, and form families and intimate relationships. In this study we examine what we have learned as we apply Socio-Emotional Relationship Therapy (SERT) with heterosexual couples of Asian heritage. SERT begins with sociocultural attunement and the assumption that relationships should mutually support each partner. Drawing on case examples, we illustrate how we practice sociocultural attunement as couples respond to the relational processes that comprise the Circle of Care (mutual influence, vulnerability, attunement, and shared relational responsibility). We emphasize three key socioemotional themes that intersect with gender: (1) intangible loss; (2) quiet fortitude/not burdening others; and (3) duty to the family.

The Impact of Couple Therapy on Service Utilization among Military Veterans: The Moderating Roles of Pretreatment Service Utilization and Premature Termination.

Couple therapy reduces relational and individual distress and may affect utilization of other health services, particularly among higher service utilizers. Although average decreases in service utilization are predicted among recipients of couple therapy, low utilizers of services may appropriately increase use. The relationship between couple therapy and service utilization was examined among a sample of 179 U.S. military veterans who received treatment in Veterans Affairs (VA) specialty couple therapy clinics. Consistent with hypotheses, overall mental and physical health visits decreased from the 12 months preceding couple therapy to the 12 months following treatment. Moderator analyses showed that decreases were greatest among individuals who were rated by their therapist as having completed a full course of couple therapy, suggesting that change was attributable to intervention. Pretreatment service utilization also moderated observed change-higher utilizers' use of services decreased substantially, whereas lower utilizers' slightly increased. Cost analyses revealed that the estimated per person mean cost in our sample decreased by $930.33 in the year following compared to the year prior to couple therapy, as per 2008 VA cost data. As service utilization data were only available for one partner and only for 1 year posttherapy, the true magnitude of this effect may be underestimated. Our findings are relevant to policy makers as they demonstrate that couple therapy reduces average service utilization and associated costs and addresses calls for analyses of cost effectiveness of systemic interventions.

Alcohol-Focused Behavioral Couple Therapy.

Alcohol Behavioral Couple Therapy (ABCT) has emerged over the last 30 years as a highly efficacious treatment for those with alcohol use disorders. This review highlights the historical and conceptual underpinnings of ABCT, as well as the specific treatment elements and structure. Proposed active ingredients, moderators, and mediators of treatment outcome are discussed. Efficacy is evaluated for reductions in identified patient drinking, improved relationship functioning, and reductions in intimate partner violence. Adaptations of ABCT for substances other than alcohol are described. Other adaptations, including brief interventions, interventions addressing PTSD and TBI along with alcohol use, and interventions deliverable via technology platforms are described. Additional cost-benefit and cost-effectiveness findings supporting the economic value of ABCT are noted. Future directions for research in this area include possible adaptations for female identified patients, nontraditional couples, LGBT partners and dyads involving nonintimate partner relationships. The development of more flexible models and enhanced dissemination strategies may improve clinical uptake and utility as well as increasing the feasibility of this treatment for integrated healthcare settings.

A Review of the Research in Emotionally Focused Therapy for Couples.

Emotionally Focused Therapy for Couples (EFT) is a brief evidence-based couple therapy based in attachment theory. Since the development of EFT, efficacy and effectiveness research has accumulated to address a range of couple concerns. EFT meets or exceeds the guidelines for classification as an evidence-based couple therapy outlined for couple and family research. Furthermore, EFT researchers have examined the process of change and predictors of outcome in EFT. Future research in EFT will continue to examine the process of change in EFT and test the efficacy and effectiveness of EFT in new applications and for couples of diverse backgrounds and concerns.

Integrative Behavioral Couple Therapy: Theoretical Background, Empirical Research, and Dissemination.

Integrative Behavioral Couple Therapy (IBCT), developed by Drs. Andrew Christensen and Neil Jacobson, builds off the tradition of behavioral couple therapy by including acceptance strategies as key components of treatment. Results from a large randomized clinical trial of IBCT indicate that it yields large and significant gains in relationship satisfaction. Furthermore, these benefits have been shown to persist for at least 5 years after treatment for the average couple. Not only does IBCT positively impact relationship constructs such as satisfaction and communication, but the benefits of therapy extend to individual, co-parenting, and child functioning. Moreover, IBCT has been shown to operate through the putative mechanisms of improvements in emotional acceptance, behavior change, and communication. IBCT was chosen for nationwide training and dissemination through the Veteran Affairs Medical Centers. Furthermore, the principles of IBCT have been translated into a web-based intervention for distressed couples, OurRelationship.com. IBCT is continuing to evolve and grow as research and technologies allow for continued evaluation and dissemination of this well-supported theoretical model.

The Embodied Attunement of Therapists and a Couple within Dialogical Psychotherapy: An Introduction to the Relational Mind Research Project.

In dialogical practice, therapists seek to respond to the utterances of clients by including in their own response what the client said. No research so far exists on how, in dialogs, therapists and clients attune themselves to each other with their entire bodies. The research program The Relational Mind is the first to look at dialog in terms of both the outer and the inner dialogs of participants (clients and therapists), observed in parallel with autonomic nervous system (ANS) measurements. In the ANS, the response occurs immediately, even before conscious thought, making it possible to follow how participants in a multiactor dialog synchronize their reactions and attune themselves to each other. The couple therapy case presented in this article demonstrates how attunement is often not a simple "all at the same time" phenomenon, but rather a complex, dyadic or triadic phenomenon which changes over time. In the case presented, there was strong synchrony between one therapist and one client in terms of their arousal level throughout the therapy session. It was also observed that high stress could occur when someone else was talking about something related to the participant, or if that person mirrored the participant's words. Overall, it seems that in evaluating the rhythmic attunement between therapists and clients it is not enough to look at single variables; instead, integrated information from several channels is needed when one is seeking to make sense of the embodiment.

A Video Recall Study of In-session Changes in Sentiment Override.

This study examines in-session changes in sentiment override over the first three sessions of couple therapy. Couples viewed a video recording of therapy sessions immediately after each of the first three sessions and continuously rated their level of sentiment override. Ninety-eight changes were randomly chosen for analysis. Three talk turns prior to each change was coded using the Family Relational Communication Control Coding System. Results show that changes in sentiment override occur frequently. Repeated incidents of communication control were related to negative change in sentiment override for females. Repeated incidents of being left out of the conversation were related to negative changes in sentiment override for females and positive changes for males.

Couple-based interventions for psychopathology: a renewed direction for the field.

This article provides a rationale and empirical support for providing couple-based interventions when one partner in a relationship is experiencing individual psychopathology. Several investigations indicate that relationship distress and psychopathology are associated and reciprocally influence each other, such that the existence of relationship distress predicts the development of subsequent psychopathology and vice versa. Furthermore, findings indicate that for several disorders, individual psychotherapy is less effective if the client is in a distressed relationship. Finally, even within happy relationships, partners often inadvertently behave in ways that maintain or exacerbate symptoms for the other individual. Thus, within both satisfied and distressed relationships, including the partner in a couple-based intervention provides an opportunity to use the partner and the relationship as a resource rather than a stressor for an individual experiencing some form of psychological distress. The authors propose that a promising approach to including the partner in treatment involves (a) integrating intervention principles from empirically supported interventions for individual therapy for specific disorders with (b) knowledge of how to employ relationships to promote individual and dyadic change. Based on this logic, the article includes several examples to demonstrate how couple-based interventions can be focused on a specific type of psychopathology, including encouraging empirical findings for these interventions. The article concludes with recommendations for how clinicians and researchers can adapt their knowledge of couple therapy to assist couples in which one partner is experiencing notable psychological distress or diagnosable psychopathology.